REQUEST FOR REGISTRATION OF AN INDUSTRIAL DESIGN

(The following is to be filled in by the Intellectual Property Office) APPLICATION No.:

THE UNDERSIGNED HEREBY REQUEST THAT THIS INDUSTRIAL DESIGN APPLICATION BE REGISTERED.

FILING DATE: Date of Receipt:

Box No. 1 TITLE OF THE DESIGN

Box No. II APPLICANT (WHETHER OR NOT ALSO MAKER). Use this box for indicating the applicant or, if there are several applicants, one of them. If more than one person (includes, where applicable, a legal entity) is involved, continue in supplemental box. The person in this box is (check one only): Name and address: [ ] applicant and designer

[[

] applicant only

Telephone number: (including area code) Country of Nationality:

Fax Number:

E-mail address: Country of residence:

Box No. III DESIGNER/S. A separate sub-box has to be filled in respect of each person. If the following two sub-boxes are insufficient, continue in the Supplemental Box. (giving therein for each additional person the same indications as those requested in the following two sub-boxes) or by using a continuation sheet. The person in this box is (check one only): Name and address: [ ] applicant and designer [ ] designer only

If the person identified in this sub-box is applicant (or applicant and maker), indicate also: Country of nationality: Country of residence:
The person in this sub-box is (check one only):

[ ] applicant and inventor

[ ] maker only

Name and address:

If the person identified in this sub-box is applicant (or applicant and inventor), indicate also: Country of nationality: Country of residence:

Sheet number 2 Box No. IV AGENT (IF ANY) OR COMMON REPRESENTATIVE (IF ANY); ADDRESS FOR NOTIFICATIONS (IN CERTAIN CASES) A common representative may be appointed only if there are several applicants and if no agent is or has been appointed: The common representative must be one of the applicants. The following person (include, where applicable, a legal entity) is hereby/has been appointed as agent or common representative to act on behalf of the applicant(s) before the Intellectual Property Office. Name and address, including postal codes: CARAG, CABALLES, JAMORA & SOMERA LAW OFFICES 2nd Floor, The Plaza Royale, 120 L. P. Leviste Street Salcedo Village 1227, Makati City Telephone number: (02) 8125246 (including area code) 8125247 8125248 Fax No.: (02) 8188971 E-mail address: mail@ccjslaw.com

Box No. V PRIORITY CLAIM (IF ANY). The priority of the following earlier application(s) is hereby claimed: Country in which it was filed: Filing date Application No. (month, day, year) (1) __________________________________________________________________________________________ (2) __________________________________________________________________________________________ (3) __________________________________________________________________________________________ Box No. VI SIGNATURE OF APPLICANT(S) OR AGENT OVER PRINTED NAME(S) Applicant By: CARAG, CABALLES, JAMORA &SOMERA LAW OFFICES Agent/Representative

Attorney If the present Request form is signed on behalf of any applciant by an agent, a separate notarized power of attorney appointing the agent and signed by the applicant is required. If in such case it is desired to make use of a general power of attorney (deposited with the Intellectual Property Office), a copy thereof must be attahced to this form. Box No. VII CHECKLIST (To be filled in by the applicant) This application contains the following number of sheets: 1. 2. 3. 4. request .. description claims drawings . Total sheets sheet sheet sheets sheets This application as filed is accompanied by the items checked below:

separate notarized power of attorney power of attorney (pro-forma) priority document(s) (see Box No. V) cheque for the payment of fees deed of assignment (pro-forma) other document (specify) ________________________

Figure number(s) _______ of the drawing (if any) is suggested to accompany the abstract for publication